Healthcare Provider Details

I. General information

NPI: 1972565513
Provider Name (Legal Business Name): SAMUEL L GROSSMAN DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2006
Last Update Date: 12/06/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

181 W EMMETT ST
BATTLE CREEK MI
49037-2963
US

IV. Provider business mailing address

181 W EMMETT ST
BATTLE CREEK MI
49037-2963
US

V. Phone/Fax

Practice location:
  • Phone: 269-966-2600
  • Fax: 269-965-4773
Mailing address:
  • Phone: 269-966-2600
  • Fax: 269-965-4773

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number5101010868
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: